Kirby Road Surgery

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

The service had improved. The practice provided appropriate, accurate and up-to-date information in a variety of ways that meant information was accessible to a wide range of people and tailored to individual needs. The practice was now registered correctly with the Information Commissioner’s Office. The practice now handled complaints in a consistent and timely manner. Complaints were now investigated and used to improve the quality of care and service. The practice responded to complaints in an appropriate way, including giving information about what the person could do if they were unhappy with the practice’s response to their complaint. The outcomes of complaints were now recorded accurately. The practice encouraged people to provide feedback and sought feedback in a variety of ways. People could now access the care, support and treatment they needed, when they needed it, and in a way that worked for them. The practice monitored data and used this to continue to make improvements in access to the service. The practice sought to break down barriers some may face in accessing and receiving care and treatment.

This service scored 82 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not receive specific examples from patients about person centred care. However, the practice shared with us examples of how they made sure people were at the centre of their care and treatment choices and in partnership with them, decide how to respond to any relevant changes in their needs, including patient’s feedback. For example, medicine reviews for patients with longstanding pain included both the person’s physical and mental health and well-being. Goals were set with patients and reviews were holistic and tailored to the individual, for example included the patient’s hobbies and leisure activities.

The practice identified patients with a learning disability and offered appointments tailored to their needs, such as longer appointments and home visits, and encouraged the use of the ‘This is Me Care Passport’. This is a document to give professionals information about the autistic person or person with a learning disability or dementia as an individual to help them to support the person as best as possible. Staff told us they communicated with patients using appropriate methods, for example, not all patients received information by text message, and patients who were deaf or who had difficulty hearing were offered face-to-face appointments rather than telephone consultations. Patients’ preferences and needs were recorded on the patient’s clinical record.

Staff we spoke with told us that the practice understood the needs of its local people and had developed services in response to those needs.

People’s care and treatment was delivered in a way that met their assessed needs from services that were coordinated and responsive. Feedback we received from care home representatives were generally positive about their experience on behalf of their residents with regards to how the practice involved residents, their relatives and care home staff in decisions about their care and treatment.

People received care and treatment from services that understand the diverse health and social care needs of their local communities. For example, the practice adjusted the delivery of its services to meet the needs of people with mental health needs. The practice made reasonable adjustments when patients found it difficult to access services. The importance of flexibility, informed choice and continuity of care were reflected in the services provided. Patients could pre-book appointments, including with their preferred clinician. Clinicians could book in patients for a follow-up appointment with them, when they felt this was appropriate. The practice was usually open and appointments available between 8am and 6.30pm on weekdays. In addition, pre-bookable appointments for certain clinics were available from 7am until 8.15pm on weekdays and on Saturday mornings. The practice offered clinics dedicated for smear tests on Saturdays, called ‘Smear Saturdays’. These helped patients who may find it difficult to attend an appointment during a weekday. The practice offered certain clinics, such as for smear tests, at times when only female patients and staff would be in the building. The practice had identified this as a way to improve patient outcomes and experiences. For example, to encourage more people from ethnic minority groups to attend screening for cervical cancer and to help female victims of abuse feel more comfortable attending the practice.

We did not have any specific comments from people about information provided by the practice.

The practice had effective systems for storing and keeping confidential and sensitive personal information secure, for example patient’s current and historic medical records. The practice held and used this information in line with requirements and information security standards, including when held and used digitally. There was information in the practice and on their website advising patients how their information was stored and managed. The provider was registered as a data controller with the Information Commissioner’s Office. Online and telephone consultations and calls took place in appropriate environment to ensure confidentiality. Information the practice gave us for this inspection showed all staff had completed the training required by the practice in relation to information governance and the General Data Protection Regulation (GDPR).

The practice complied with the Accessible Information Standard (AIS), a requirement for all providers of NHS care. The AIS applies to people who use a service, and their carers or parents, who have information or communication needs because of a disability, impairment or sensory loss. For example, there was a hearing loop for people who are deaf or have difficulty hearing and the signs on the doors to clinical rooms and toilets included braille. Information was available on a television screen and various noticeboards in the practice waiting area, for example about the risks of using certain medicines for long-term pain, the signs of autism, information for unpaid or family carers, and information about issues such as female genital mutilation and adult exploitation. There were also posters throughout the practice, which had been placed at different heights and in strategic places to help make the information accessible for more people. These included information about the symptoms of diabetes, the availability of chaperones, how to provide feedback about the service, and advice and support for people experiencing domestic abuse. Information was also available on the practice’s website, including short animated videos, such as about smear tests, diabetes, and the roles of the various professionals who patients may see in the practice, to make the information accessible to a larger number of people. Information available on the practice’s website also included about the risks of using certain medicines for long-term pain and the support available for patients.

Patient views were acted on to improve services and culture by the practice. Feedback and complaints were listened and responded to and used to improve the quality of care. The member of the Patient Participation Group (PPG) we spoke with told us the practice leaders attended their meetings and communicated with them outside of the organised meetings. They told us the practice listened to any concerns they raised and responded. Where appropriate the practice had made changes and communicated these to the group.

Staff were aware of the practice’s complaints procedure and told us they would advise patients how they could make a complaint when this was appropriate. There was evidence feedback, including from complaints and patient surveys, were used to drive continuous improvement. Indicators in the GP Patient Survey published in 2023 showed lower performance data under the areas of access and patient experience. The practice were aware the results of the 2023 national GP Patient Survey showed areas where improvements could be made. The practice was proactive in ensuring there was equity in access, experience and outcomes for their patients and made changes in response to the feedback from people who used the service. They had carried out their own review using the same questions from the GP patient 2023 survey and had noted higher performance data. The practice also bought a computer survey package to help them to carry out their own survey and interpret the findings. The practice sent surveys by text message to all patients who had had an appointment with the practice that week. The practice felt that this gave results more representative of the people who used the service, as well as seeking feedback from significantly more patients than the national survey. The results collected by the practice were more positive than those in the national survey, and the practice used the feedback collected to continue to make improvements. Complaints were discussed in practice meetings. If there had not been a new complaint to discuss, previous complaints were reviewed. Leaders told us information was presented in ways that used complainants’ own language, to help maximise learning from the complaints. The practice’s Quality Assurance Manager monitored social media and responded to both critical and positive comments.

Information about how to complain, including the practice’s complaints policy and procedure, was available on the practice’s website, including visual aides. The practice’s Complaints & Comments Leaflet, available on the practice website and in waiting areas in the practice, outlined the complaints procedures, what patients could expect, and what patients could do if they were not satisfied with the practice’s response to their complaint. People could provide feedback, suggestions, comments, complaints and compliments online, by email, letter, completing a ‘complaints/comments form’ or verbally. There was also a ‘Post your feedback here’ box in the reception area and posters around the practice with a ‘QR code’ providing a link to a survey to let the practice know ‘how they did’. The practice also had a small paper version of this poster that patients could pick up in the practice and the survey was advertised in the practice newsletter. In the year leading up to this inspection, the practice had recorded 13 complaints. We looked at the records for 3 of these complaints and found the practice had handled them in a timely way and responded appropriately. There was a system for recording and acting on complaints. The practice also encouraged people to give feedback through the NHS Friends and Family Test, which could be completed online. The practice’s website included a short animated video about the NHS Friends and Family Test, to make the information accessible to a larger number of people. The practice also recorded and shared positive feedback.

At the time of this inspection, the most recent GP Patient Survey data, from April 2023, showed the practice performed below the local and national averages for the percentage of people who were: • positive about how easy it was to get through to someone at the practice on the ‘phone • very or fairly satisfied with the practice’s appointment times • positive about the overall experience of making an appointment. The GP Patient Survey is an independent national survey that tells us how people feel about their GP practice. The results of the 2024 GP Patient Survey were released shortly after this inspection. Although the 2024 survey differed to the previous years’, the results for Kirby Road Surgery showed, of the people who responded to the survey: • 60% said their overall experience of contacting the practice was fairly or very good, slightly above the local average and slightly below the national average • 52% said it was fairly or very easy to contact the practice by ‘phone, an improvement from 19% in 2023, and above both the local and national averages • 32% said it was fairly or very easy to contact the practice using their website, which was below the local and national averages. These results showed further improvement than those collected by the practice in their survey completed in October and November 2023. Patients could contact the practice online or by email and were able to book appointments by telephoning or visiting the practice.

51% of patients registered with the practice had signed up to online services. The needs of people (including those who might be digitally excluded) had been considered in relation to access. There were systems in place to support patients who face communication barriers to access treatment (including those who might be digitally excluded). Patients had timely access to appointments/treatment and action was taken to minimise the length of time people waited for care, treatment or advice. The practice monitored the quality of access and made improvements in response to findings. For example, the practice analysed data about telephone access collected electronically, and used this to make improvements, such as maximising the number of staff available to answer telephone calls at the times identified as being busiest. Information provided by the practice showed the number of telephone calls into the practice that were answered had improved from 76% in April 2023 to 94% in April 2024. The average length of time people waited for their call to be answered had more than halved to an average wait time of 2 minutes 26 seconds in April 2024.

The practice offered a range of appointment types including face-to-face, telephone and online consultations and home visits. Appointments with various clinicians were available, including with doctors, a healthcare assistant, a nurse associate, pharmacists, physician associates and practice nurses. Some staff offered steroid joint injections and minor surgical procedures. Patients with the most urgent needs had their care and treatment prioritised. Both ‘urgent, or ‘same day’, and pre-bookable appointments were available. When the practice was closed, patients were directed to access support, treatment and advice from the NHS 111 service or emergency services. The practice was a member of a wider network of GP practices known as the Chiltern Hills Primary Care Network (PCN). This PCN includes 6 GP practices working together to address local priorities in patient care. Care coordinators, health and well-being coaches, mental health practitioners, occupational therapists, paramedics, physiotherapists, podiatrists and social prescribing link workers employed by the PCN supported patients of Kirby Road Surgery. There was information available for patients to support them to understand how to access services, for example on posters in and at the entrance to the practice and on the practice’s website. The practice raised awareness of other local services and encouraged people to choose the service best able to meet their needs, such as a local pharmacist, or how to self-care for minor conditions. The facilities and premises were appropriate for the services being delivered and included toilet facilities accessible for those with mobility needs, baby changing facilities, disabled parking spaces, and level access suitable for those with wheelchairs, scooters or prams. Patients could ask for repeat prescriptions online, by using a ‘prescription request slip’ delivered to the practice, or via their local pharmacist.

We did not receive specific examples from people about equity in experiences and outcomes. However, the practice shared with us examples of how they actively pursued and listened to information about people who were most likely to experience inequality in experience or outcomes and tailored the care, support and treatment in response to this.

The practice provided care and support for a number of patients who do not speak English as their first language. When needed, there were arrangements in place for people who need translation services, including being able to easily translate the practice website and access to telephone-based interpreter services. A variety of members of staff spoke different languages and were available to support discussions when needed. Written in the relevant language, the practice advertised which staff spoke which languages and when they were usually available at the practice. Patients were informed that chaperones were available. All staff who acted as a chaperone had completed training, and staff we spoke with described a suitable procedure. A chaperone is an impartial observer present during an examination or consultation when a patient may feel vulnerable, for example during an intimate examination. A chaperone acts to protect both patients and staff.

The practice was a ‘Safe Surgery’, meaning people who were unable to provide identification to register with the practice could still access the full range of services the practice offered. People who were or might be vulnerable could register with the practice, including those with no fixed abode such as homeless people, Travellers, and refugees. The practice supported these patients, for example by providing an address for correspondence. All staff had completed training in Equality and Diversity. All staff had completed training in ‘Supporting People with Learning Disabilities’ and ‘Autism Awareness’, in addition to training that met the national draft ‘Code of Practice’ for training staff in supporting people with a learning disability and autistic people. The practice had an area dedicated to ‘Pride’ information in the waiting area and on the practice website. Staff were committed to celebrating “love, diversity, inclusion and the importance of being who you are”. Staff wore ‘NHS Rainbow Badges’ to show they offered open, non-judgemental and inclusive care for patients and their families who identify as LGBTQIA+ to help reduce inequalities in their experiences of healthcare.

Care home representatives were positive in their feedback, regarding planning for the future. They told us staff supported people to make informed choices about their care and plan their future care, while they had the capacity to do so. Relatives and carers were involved in considering the patients’ choices and decisions, where appropriate.

Staff we spoke with told us that people were supported to make informed choices about their care and plan their future care while they have the mental capacity to do so.

The practice had systems and processes in place to identify people who may be approaching the end of their life (including those with protected characteristics under the Equality Act and people whose circumstances may make them vulnerable). Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions were made in line with relevant legislation and were appropriate. Patients, their relatives and carers were involved in decisions about DNACPR. There was a process in place to ensure DNACPR forms were reviewed when the patient’s condition or circumstances changed. The practice shared information about DNACPR decisions with staff and other appropriate services and liaised with them when needed. We also found elements of outstanding practice, including the practice ran a search every 3 months to make sure decisions and documentation were up-to-date and complete. Through this search, the practice identified times when information had been altered by other services and worked with them to make sure the decisions and documentation were up-to-date and reflected the patients’ wishes.